Gastrointestinal Diseases

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Diagnostic Procedures

Upper GI tract study (Barium swallow)

Pre procedure

• examination of Upper GI under fluoroscopy after intake of barium sulfate

• NPO after midnight prior to the day of the test

Post-Procedure

•laxative (may be prescribed)

• increase oral fluids

• monitor passage of barium stools                           

Lower GI tract study (Barium enema)

    fluoroscopic and radiographic examination of large intestine after rectal instillation of barium sulfate.

PreOp:

• low residue diet for 1-2 days before

• clear liquid and laxative the evening before the test

• NPO midnight prior to the day of the test

• cleansing enemas on morning of test

PostOp:

• same as Upper GI.

•Notify Physician if no bowel movement within 2 days.

UGI Endoscopy

Direct visualization of esophagus , Stomach and duodenum

•Obtain written consent

•NPO for 6-8 Hours

•Anticholinergic (ATSO4) as ordered ,To reduce Mucus secretions

•Sedatives ,Narcotics,Tranquilizers, To relax the Client (diazepam, Meperidine HCL)

•Remove dentures bridges, To prevent airway obstruction

•Local spray anesthetic on the posterior pharynx-Instruct not to swallow saliva .

Colonoscopy

Fiberoptic endoscopic study of large intestine

• patient side-lying / knee-chest position.

PreOp:

•  Cleansing of colon

• Clear liquid diet on noon day before the test

• NPO midnight of test

• Midazolam IV for sedation

PostOp:

• Bed rest until alert.

• Monitor for signs of perforation.

• Report any bleeding.

Cholecystography, Cholangiography

• Involves visualization of structures with use of a dye.

• Always ask about allergies to iodine or seafood.

Fecal Analysis

Stool for Occult Blood  (guiac stool exam)

•Detect GI bleeding

•Increase fiber diet 48 to 72 hours

•No red meats , poultry ,fish ,turnips ,horse radish

Stool for Ova and parasites

•Send fresh warm stool specimen

•Stool culture

•Sterile test tube /cotton tipped applicator

Stool for lipids

•Assess steatorrhea

•Increase fat diet, No alcohol for 3 days

•72 hour stool specimen (store on ice)

Measures secretion of HCL and pepsin

•NPO for 12 hours

•NGT is inserted , connected to suction

•Gastric contents collected every 15 minutes to 1 hour

  

Stomatitis

•An inflammation of the mucous lining in the mouth.

•Can be caused by poor oral hygiene, poorly fitted dentures, immunocompromised, mouth burns from hot food or drinks, medications (especially chemotherapy), infections or allergic reactions, exposure to radiation.

Assessment

•Burning sensation

•Canker sores(small sores or ulcers  that are painful) = cold sores = virus

•Excessive salivation

•Halitosis (unpleasant odor of the breath) 

•Xerostomia (abnormal dryness of the mouth due to insufficient secretions) – often with radiation

•Erythema of the mucous membranes

•White patches = thrush à candidiasis

Screening & Diagnosis:

•Medical History – may disclose dietary deficiency, allergic reaction & systemic disease.

•Physical examination – (+)apthous ulcers (well circumscribed oral lesions w/ white centers & reddish rings around the periphery.

•Scraping of the lining of the mouth – (+) infectious causative agent

Treatment:

•Antibiotics : tetracycline (Sumycin®) , chlorhexidine gluconate (PerioGard®, Peridex®)

•Anti-fungal: nystatin suspension, clotrimazole (Mycelex Troches®)

•Analgesics/topical anesthetics: lidocaine, benzocaine (Americaine®, Anbesol®), sulcrafate, orabase

•Antiviral: acyclovir (Zovirax®)

Implementation

•Instruct patient regarding good oral hygeine

•Avoid foods that are irritating

•Adequate fluid intake

Gastroesophageal Reflux

•A condition in which stomach acid bile flows back into the esophagus.

•It results from inability of the lower esophageal sphincter (LES) to close fully, thus allowing stomach contents to flow freely into the esophagus.

Assessment

•Heartburn

•Chest pain, especially at night while lying down

•Dysphagia

•Regurgitation of food or sour liquid

•Cough, hoarseness, voice changes

Implementation

•low-fat, high-fiber diet, avoid caffeine, tobacco, carbonated beverages.

• avoid eating and drinking 2 hours before bedtime.

• elevate head of bed

• avoid cholinergics which delay stomach emptying

• Instruct regarding meds: antacids, H2 receptor antagonists.

Esophagitis

•(inflammation –esophagus)

•Inflammation of the lining of esophagus.

•Caused by an infection or irritation of the esophagus (due to backflow of acid fluid from the stomach/GERD, vomiting, surgery, medications).

Assessment

•dysphagia (difficult/painful swallowing)

•heartburn

•esophageal pain

•acid regurgitation

•belching

Screening & Diagnosis:

•Physical examination – reveals tachypnea, thrush in the oropharynx, & dental erosions

•Upper GI x-ray w/ barium – esophageal motility abnormalities, esophageal strictures, gastric outlet obstruction.

•Biopsy (sample of esophageal tissue is removed then sent to the lab. to be examined under the microscope)

•Esophagogastroduodenoscopy (EGD) – reveals irritated, inflamed & eroded areas

Implementation

•Small frequent meals

•elevate head of bed 4 to 8 inches

• no meals 2 hours before bedtime

•Avoid irritating foods

Medications

• Antacids

•H2 recptor antagonist

•Proton pump inhibitor

Hiatal Hernia

•Sliding hernia: gastroesophageal junction and part of stomach slide upwards.

•Paraesophageal hernia: part of stomach turns adjacent to esophagus

  Assessment

•Heartburn

•Belching

•Substernal/epigastric pressure or pain after eating & when lying down

•Hiccups

•Dysphagia, feeling of fullness

Diagnosis: Chest X-ray or Barium swallow

                                                  Barium swallow images for hiatal hernia

Implementation:

• If asymptomatic – no treatment necessary

• Small frequent meals

• Elevate head of bed to reduce acid reflux

• Avoid activities that increase abdominal pressure:

•(lifting heavy objects, bending over, etc)

  

Medications

•Antacids

•Antiemetics

•Histamine receptor Antagonist

•Gastric Acid secretion Inhibitors

  

AVOID

•Anticholinergics

•Xanthine derivatives

•Ca-channel blockers

•Diazepam

Implementation

•Small frequent meals

•Elevate head of the bed

•Avoid factors that increases abdominal pressure

  

Surgery
NissenFundoplication (Gastric wrap Around)

Postop care

•Facilitate airway clearnce

•Semi-fowlers position

•Reinforce DBCT exercise

•Drainage from NG tube returns to yellowish green within first 8 to 12 hours post op

•Oral fluids after peristalisis returns

•Small frequent meals

•Avoid gas forming food

Peptic ulcer disease

GASTRITIS

Diffuse or localized inflammation of the gastric mucosa

Acute gastritis

Short –term inflammatory process due to ingestion of chemical agents or food products that irritate and erode gastric mucosa

Chronic gastritis

Type A

Autoimmune in nature

Atrophic gastritis, gastric Ca , pernicious anemia

 Type B

Asociated with helicobacter pylori

  

Assessment

•Anorexia

•Heartburn

•Nausea and vomitting

•Sour taste in the mouth

•Belching

•Epigastric pain

Implementation

•Assess for GI bleeding

•Small frquent meals

•Avoid irritating foods

•Avoid smoking

  

Gastric Ulcer 

•Normal or decreased acid production

•Decreased mucosal resistance

•Chronic NSAID use

•Pain gets worse after meals

                                                              Gastric ulcer pics  

Duodenal Ulcer

May be asymptomatic

Pain ( midepigastric)

Meds for gastritis, GERD, PUD.

Antacids:

• Aluminum hydroxide (Amphogel)

• Bismuth subsalicylate (Pepto-Bismol)

• Calcium carbonate (Tums)

• Magnesium hydroxide (Milk of Magnesia)

GI protectors

• Misoprostol (Cytotec)

• Sucralfate (Carafate)

H2 Receptor Antagonists

•Cimetidine (Tagamet)

•Ranitidine (Zantac)

•Famotidine (Pepcid)

Antimicrobials

• Amoxicillin (Amoxil)

• Clarithromycin (Biaxin)

• Metronidazole (Flagyl)

• Tetracycline (Achromycin

Proton Pump Inhibitors

• Omeprazole (Prilosec)

• Iansoprazole (Prevacid)

SURGERY

Vagotomy

•Resection  of the vagus nerve

•Decreased cholinergic stimulation

Pyloroplasty

•Surgical dilation of the pyloric sphincter

•Improves gastric emptying of the acidic chyme

Antrectomy

•Removal of 50 % of the lower part of the stomach

Types

•Billroth I   ( gastroduodenostomy)

•Billroth II  ( Gastrojejunostomy  )

Subtotal gastrectomy with bilroth1/bilroth 2

Total gastrectomy

Potential complication following surgery

•Respiratory ( Atelectasis)

•Bleeding

•Dumping syndrome

DUMPING SYNDROME

Early signs and symptoms ( 5 to 30 min p.c.)

•Weakness

•Tachycardia

•Dizziness

•Diaphoresis

•Pallor

•Feeling of fullness or discomfort

•Nausea

•Explosive diarrhea

Esophageal Varices

•Elevated portal vein pressure

•Tortous dillated thin walled veins

Assessment

•Asymptomatic

•If massive bleeding ( signs of shock)

Medication

•Vassopressin ( pitressin)

•Betablockers

•Nitrates

Implementation

•Assess vital signs

•Assist patient to avoid straining and vomitting

•Assess for bleeding

•assist with Sengstaken tube

Sengstaken blakemoreTube

•To compress esophageal varices

Liver Cirrhosis

•Chronic, degenerative liver disease manifested by diffuse destruction & fibrotic regeneration of hepatic cells that leads to anatomic alteration & partial/complete occlusion of blood in the liver.

Types

•Laennec’s cirrhosis

•Biliary cirrhosis

•Postnecrotic cirrhosis

•Cardiac cirrhosis

Assessment

• Fatigue
•  nausea, vomiting
•  itchy skin, jaundice
•  spider angiomas
• palmar erythema
•  nosebleeds, GI bleeds, bruises
•  ascites
•   esophageal varices - CNS: lethargy

Analysis:

•altered thought process

•bleeding risk

•Impaired skin integrity

•Altered nutrition

Implementation

•Check skin, gums and stool for bleeding

•Avoid aspirin, NSAIDS, alcohol

•Monitor weight

•Monitor abdominal circumference

If ascites interferes with breathing- - high fowler’s

Hepatitis

A	Contaminated Water/food/shellfish	-2-6 weeks incubation - 0% become chronic
B	Blood transfusions Sexual contact Parenteral	-2-6 months incubation -10% become chronic
C	Blood transfusions Sexual contact Parenteral	- 1-2 months incubation
D	Only in patients with hepatitis B parenteral	incubation period: 21 to 140 days
E	Fecal oral	incubation period: 15 to 65 days

Assessment:

PREICTERIC:

• nonspecific: fatigue, anorexia, malaise, weakness

• low grade fever

ICTERIC

•Jaundice

•Pruritus

•Brown-colored urine

•Lighter-colored stools

•Decrease in preicteric phase symptoms

POSTICTERIC

•Energy level increase

•GI symptoms are minimal to absent

•Pain subsides

•Serum bilirubin & enzyme levels return to normal

Treatment:

•Diet therapy: high-calorie, moderate-protein, low fat

•Activity – rest

Medications

•Interferon alpha (IM or SC injection)

•lamivudine (Ephivir HBV)

•ribavirin  (Rebetol®)

•Vitamins & minerals

•Vaccines for preventive measures (only for hepa A  & B – 3 series shots)

•Herbal medicines: licorice root

Implementation

• Provide bed rest

• Provide high-calorie diet

• Monitor for signs of GI bleeding

•Limit visitors/ isolation procedures if infectious

Cholecystitis

•Inflammation of the gallbaldder

•Associated with cholelithiasis

Assessment

•Nausea and vomitting

•Belching

•Indigestion

•+ murphy’s sign

•Pain right upper quadrant

Dissolution therapy 

•  Ursodiol(Actigall)
•  Chenodiol (Chenix)

Analgesics: meperedinehydrochloride(Demerol)

Anti-emetics: promethazine (Phenergan, Prorex, Anergan)

Surgical

•Cholecystectomy – removal of the gallbladder

•Choledochotomy – incision of the common bile duct to remove the stone

Postoperative:

 Monitor T-tube drainage(up to 500 ml in 24 hours is normal) 

Pancreatitis

Acute or chronic inflammation of the pancreas wherein there is abnormal pancreatic enzyme activation in the pancreas

Acute Pancreatitis	Chronic Pancreatitis
•         Pain midepigastric          Left upper quadrant •         Tachycardia •         Increased temperature •         Abdominal distention & rigidity •         ↓ Bowel sounds •         Nausea & vomiting •         Cold clammy skin •         Mild jaundice •         Cullen’s sign – discoloration of the abdomen and periumbilical area •         Turner’s sign -  bluish discoloration of the flanks	•         Reoccurring abdominal pain & tenderness •         steatorrhea & foul smelling stools •         Left upper quadrant mass •         Weight loss •         Muscle wasting •         Jaundice

Blood chemistry – reveal ↑ amylase, bilirubin, lipase, trypsinogen, alkaline phosphatase glucose, ↓ calcium

Medications

•Analgesics: acetaminophen (Tylenol®), tramadol (Ultram®)

•Antibiotics: imipenem and cilastatin (Primaxin®)

•Pancreatic enzymes: pancrelipase (Lipancreatin®)

•H2 blockers: cimetidine (Tagamet®), ranitide (Zantac®)

Diet therapy: low-fat, low-protein, high-carbohydrate, small frequent feedings with restricted

Implementation

•Monitor vital signs, assess level of pain.

•Maintain NPO and provide NG tube suction if vomiting in acute phase

•Follow dietary recommendations & restrictions

•Instruct patient about the importance of avoiding alcohol and smoking cessation.

APPENDICITIS (epityphlitis)

•Inflammation of the appendix caused by an obstruction of the narrow appendiceal lumen secondary to impacted fecal material, kinking infectious swelling fibrous over growth or lymph node swelling.

•Occurs in all age groups but rare in infants.

Types:

•Simple appendicitis

•Gangrenous appendicitis

•Perforated appendicitis

Assessment

•(+) Rebound tenderness

•(+) Rovsing’s sign

•(+) Psoas sign  

•(+) Obturator sign

•Low-grade fever

•Nausea & vomiting

•Loss of appetite

•Inability to pass gas

Medication

Antibiotics : cefuroxime, metronidazole

Surgical

•Appendectomy – surgical removal of the appendix to decrease the risk of perforation.

•Laparoscopic surgery – remove appendix using a pencil-thin tube; provides less scarring & faster recovery.

Implementation

• maintain bed rest

• keep client NPO

• semi-fowler’s position

•monitor for signs of perforation and systemic infection

Postoperative:

• monitor vital signs

• monitor fluid intake and output

• monitor bowel sounds

• monitor dressing for drainage or signs of infection

 DIVERTICULOSIS

A condition when multiple diverticula exist without symptom or inflammation.

Diverticulitis

An inflammation of one or more diverticula

Assessment

•Lower left side abdominal pain

•Abdominal tenderness

•Change in bowel

•Vomiting

•Bloating

•Anorexia

•Trace (occult) blood in the stool

•Urinary frequency from pressure

•Low grade-fever

Diagnosis

•Physical examination & digital rectal exam

•Hemooccult or guaiac testing Complete blood count - ↑ WBC, RBC loss

•Abdominal x-ray/ CT scan

• Barium enema

•Colonoscopy or sigmoidoscopy

Medications

•Opioid Analgesics: meperedine(Demerol®), pentazocine (Talwin ®)

•Antispasmodics: propantheline bromide(Pro-Banthine®), oxyphencyclimine(Daricon®)

•Antibiotics: metronidazole (Flagyl®), clindamycin (Cleocin®), cefoxitin (Mefoxin®)

•Bulk preparation: psyllium(Metamucil)

•Stool softener: docusate(colace)

Surgical

•Bowel resection with primary anastomosis

•Temporary or permanent colostomy

  

Implementation

•Bed rest during acute phase

•NPO during acute phase

•Administer medications as ordered

•Instruct to avoid straining

•Increase fluid intake

•Dietary modification

•Provide colostomy care ( if present)

Inflammatory bowel diseases

	Ulcerative colitis	Chron’s disease
Pathology And location	•         mucosal ulceration •         begins at rectum and progresses towards ileocecal junction •         Involves entire colon up to ileum	transmural thickening granulomas •         Ileum, ileocolic colon
Assessment	•         Abdominal cramping: left lower quadrant •         Abdominal distention •         Nausea & vomiting •         Fatigue •         Bloody purulent stool •         Fever •         Tenesmus •         Weight loss, •          anorexia •           •	•         Diarrhea •         Possible steatorhhea •         Weight loss + malabsorption à deficiencies •         Diffuse abdominal tenderness •         Abdominal pain & cramping •         Fever •           •

Medication

•Anti-inflammatory: sulfasalazine (Azulfidine),mesalamine (Asacol, Rowasa), olsalazine, salicylate

•Corticosteroids: budesonide (Entocort EC), methylprednisolone, prednisone

•Antibiotics: metronodazole (Flagyl),ciprofloxacin (Cipro)

•Immune system suppresors : azathiophrine(Imuran), mercaptopurine (Purinethol), methotrexate, (rheumatrex)

•Anti-diarrheals: psyllium powder (Metamucil), loperamide(Imodium)

Surgery

•Total proctocolectomy/ Ileostomy

•Kock ileostomy

  

Watch for dehydration

• Monitor stool frequently and consistency

• During acute phase NPO

• Watch signs of gastrointestinal obstruction

• Dietary modification

Colostomy

•is a surgical procedure that involves connecting a part of the colon onto the anterior abdominal wall

-Cancer

-Ulcerative Colitis, Chrons

-Diverticulitis
Congenital conditions: Hirschprung's disease, rectal atresia, and megacolon

-Bowel Obstruction

-Traumatic Injury

•Permanent Ostomy
Constructed when the rectum, colon, or the bladder have been removed

•Temporary Ostomy

 Considered temporary if it is going to be reversed

An ileostomy is astoma that has been constructed by bringing the end of the small intestine (the ileum) out onto the surface of the skin..

Colostomy care:

•Remove pouch when 1/3 full

•Cleanse stoma with soft cloth and water or mild soap

•Dry skin thoroughly before applying pouch

•Use skin barrier powder or paste to protect from fecal drainage.

•Irrigation of stoma: be gentle – never force catheter

•Allow client to verbalize feelings about colostomy